UM Medical Director - Internal Medicine - Remote

UnitedHealth Group•Springfield, MA

3d•Remote

About The Position

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The company fosters a culture guided by diversity and inclusion, offering comprehensive benefits and career development opportunities. Clinical Advocacy & Support focuses on the customer journey, delivering clinical coverage and medical claims reviews, and empowering providers and members to improve health outcomes, reduce care variation, and manage healthcare costs. The Medical Director provides physician support to Enterprise Clinical Services operations, which is responsible for the initial clinical review of service requests. This role involves collaborating with Enterprise Clinical Services leadership and staff to establish, implement, support, and maintain clinical and operational processes related to benefit coverage determinations, quality improvement, and cost-effectiveness. The Medical Director's activities primarily involve applying clinical knowledge in utilization management, focusing on post-service benefit and coverage determination or medical necessity, and communicating with network and non-network physicians and other Enterprise Clinical Services. The Medical Director also collaborates with a multidisciplinary team in managing medical benefits, often involving the member’s primary care provider or specialist physician, to ensure appropriate and cost-effective quality medical care for members. This position offers the flexibility to work remotely from anywhere within the U.S.

Requirements

M.D. or D.O.
Active unrestricted license to practice medicine
Board certified in Internal Medicine
Ability to obtain additional licenses as needed
5+ years of clinical practice experience after completing residency training
Proven sound understanding of Evidence Based Medicine (EBM)
PC skills, specifically using MS Word, Outlook, and Excel
Participate in rotational holiday and call coverage

Nice To Haves

Licensed in MA or MN
Utilization Management or clinical coverage review experience for an insurance or managed care organization OR 2+ years of Hospitalist Experience
Innovative problem-solving skills
Proven presentation skills for both clinical and non-clinical audiences
Demonstrated excellent oral, written, and interpersonal communication skills, facilitation skills
Current licensure in New Mexico, Arizona or Indiana

Responsibilities

Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations
Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements
Engage with requesting providers as needed in peer-to-peer discussions
Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
Participate in daily clinical rounds as requested
Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
Communicate and collaborate with other internal partners
Call coverage rotation